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ADVANCES IN CHILDHOOD ACUTE ADVANCES IN CHILDHOOD ACUTE
LEUKEMIAS : GENERAL OVERVIEWLEUKEMIAS : GENERAL OVERVIEW
DaniDanièèle SOMMELETle SOMMELET
EuropeanEuropean ScientificScientific SeminarSeminar
Luxemburg, 3.11.2009Luxemburg, 3.11.2009
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DefinitionDefinition ofof acute acute leukemiasleukemias
MalignantMalignant processprocess comingcoming fromfrom
lymphoidlymphoid (85 %) or (85 %) or myeloidmyeloid (15 %) (15 %)
precursorprecursor cellcellCombinedCombined withwith
dysregulationdysregulation ofof followingfollowing programsprograms
::•• proliferation• differentiation• senescence• apoptosisThe most
frequent childhood cancer (30 %)
420 new cases per year in France 0 – 15 yrs+ 50 15 – 19 yrs Peak
age 2 – 4 yrs ALL
No peak age AML
Acquired genetic abnormalities
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Interactions Interactions betweenbetween thethe
patientpatientandand hishis diseasedisease (1)(1)
Patient
22)) Subtle genetic alterationsSubtle genetic alterationsor
variations affecting or variations affecting response to specific
response to specific environmental exposuresenvironmental
exposures
1)1) PredisposingPredisposing factorsfactorsKnown DownDown’’s
syndromes syndrome< 10 %< 10 %
ImmunodeficienciesImmunodeficiencies
Chromos. instability syndromesChromos. instability syndromes
Possible Genetic variability in Genetic variability in
xenobioticxenobioticmetabolism (drugs, environment)metabolism
(drugs, environment)DNA repair pathwaysDNA repair
pathwaysCellCell--cycle checkpoint functionscycle checkpoint
functions
3) Role of combination ofparents/child genotypes
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InteractionsInteractions betweenbetween thethe
patientpatientandand hishis diseasedisease (2)(2)
CytologyCytology : 3 ALL, 8 AML: 3 ALL, 8 AMLImmunoImmuno
phenotypephenotype
ConventionalConventional andand
molecularmolecularcytogeneticscytogeneticsTarget Target
molecularmolecular biologybiologyGlobal Global approachesapproaches
: : transcriptometranscriptome,CGH ,CGH arrayarray, SNP, , SNP,
proteomeproteome
The leukemic cell
Diagnosis, lineage, prognosis, residual disease,
therap.target?
Chromosom. andmolecular diagnosis, MRD, leukemogenesis
Subsequent consequences of genetic abnormalitiesImmunological
responseNeoangiogenesis
In vitro cell cultures Animal models
+ stroma
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AdvancesAdvances (1)(1)
SurvivalSurvival rate : 1 % 1960 rate : 1 % 1960 85 % (ALL), 60
% (AML)85 % (ALL), 60 % (AML)
WhyWhy ??•• (Inter)(Inter)--national national
therapeutictherapeutic trials, trials, supportivesupportive
carecare•• BetterBetter knowledgeknowledge ofof
prognosticprognostic factorsfactors to to stratifystratify
patientspatients•• IImprovedmproved understandingunderstanding ofof
geneticgenetic abnormalitiesabnormalities involvedinvolved
in in leukemogenesisleukemogenesis•• The follow-up of response
to CT, evaluation of minimal
disease• Development of new target drugs aiming to cure
more and better
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AdvancesAdvances (2)(2)
Strict organisation Strict organisation ofof pediatricpediatric
oncologyoncology ::everywhere, the same objectives, the same rules,
referentcentres with appropriate technic equipment
More More andand more more sophisticatedsophisticated
biologybiology ::•• To To classifyclassify, , stratifystratify atat
diagnostic diagnostic andand thereafterthereafter•• To To
betterbetter understandunderstand leukemogenesisleukemogenesis•• To
To contributecontribute to to therapeutictherapeutic
innovationinnovation•• To propose To propose
epidemiologicalepidemiological studiesstudies andand to combine to
combine
themthem withwith biologicalbiological criteriacriteria ??•• To
To preventprevent thethe diseasedisease ??
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CurrentCurrent riskrisk stratification in ALstratification in
AL
CytologyCytology
ClinicalClinical variables : age, WBCvariables : age, WBC
ImmunophenotypeImmunophenotype
DetectionDetection ofof cytogeneticcytogenetic or or
molecularmolecularlesionslesions
EarlyEarly responseresponse to to therapytherapy (ALL)(ALL)
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BPCBPC--ALL ALL prognosticprognostic factorsfactors atat
diagnosisdiagnosisriskrisk groups groups (1)(1)
Age : Age : < 1yr< 1yr, , (> 10 yrs)(> 10 yrs)
WBCWBC > or < 50 000/mm> or < 50 000/mm33
CytologyCytology : L1 / L2 : : L1 / L2 : NoNoL3 (L3
(BurkittBurkitt) treated differently) treated differently
ImmunophenotypeImmunophenotype :BPC:BPC--ALLALLTT--ALLALL
5 yr DFS30-50 %
85 % 75 %
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BPCBPC--ALL ALL prognosticprognostic factorsfactors atat
diagnosisdiagnosisriskrisk groups groups (2)(2)
CaryotypeCaryotype and molecular geneticsand molecular
geneticsHigh risk,High risk, N < 10 % : N < 10 % :
unfavorable unfavorable genetic criteriagenetic criteria•• t (9;22)
(q34; q11) BCR t (9;22) (q34; q11) BCR –– ABAB 22--3 %3 %•• IKZF1
mutation or del, without BCR IKZF1 mutation or del, without BCR ––
ABLABL•• t (4;11) (q21;q23) MLL t (4;11) (q21;q23) MLL –– AF4AF4
22--3 %3 %•• hypodiploidyhypodiploidy ≤≤ 44 44 chrchr 11--2 %2 %••
intrachromosomalintrachromosomal amplification on chr.21
amplification on chr.21
(AML1)(AML1)
5 yr DFS
20 > 40 %20 %30-50 %40-50 %29 %
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BPCBPC--ALL ALL prognosticprognostic factorsfactors atat
diagnosisdiagnosisriskrisk groups groups (3)(3)
Non Non unfavorableunfavorable geneticgenetic criteriacriteria N
N # 50 %# 50 %
5 yr DFS5 yr DFS•• HyperdiploidyHyperdiploidy > 50 > 50
chrchr 85 85 –– 90 %90 %
•• t (12;21) TEL t (12;21) TEL –– AML1 (RUNX1) AML1 (RUNX1) 85
85 –– 90 %90 %
•• t (1;19) E2A t (1;19) E2A –– PBX1 PBX1 85 85 –– 90 %90 %
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PrognosticPrognostic factorsfactors inin--ALLALL
WBCWBC > 200 000/mm> 200 000/mm33
ImmunophenotypeImmunophenotype (CD(CD1010, M, Myy))
CytogeneticsCytogenetics ±± IncidenceIncidencet
(1;14)(p33,q11)SILt (1;14)(p33,q11)SIL--TALTAL 1010--30 % TAL30 %
TALt (10 ; 14) (q24 ; q11)t (10 ; 14) (q24 ; q11)
or t (7 ; 14) (q35 . q24)or t (7 ; 14) (q35 . q24)t (5;14) (q35
; q32)t (5;14) (q35 ; q32) 20-25 % TLX3 / HOX11
* TLX3/HOX11 expression adverse outcome (FRALLE93)* Negative
role of cryptic changes
5 % TLX1 / HOX11
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Minimal Minimal residualresidual diseasedisease : a major : a
major criteriacriteria ofoftherapeutictherapeutic
decisionaldecisional value (ALL)value (ALL)
MethodsMethods : : CytologyCytology
BloodBlood, , bonebone--marrowmarrow2 points2 points - d21 /
29d21 / 29
- d35 / 42d35 / 42•• LowLow riskrisk MRD MRD ≤≤ 1010--44
•• HighHigh--riskrisk ofof relapses MRD relapses MRD > 10>
10--22
•• IntermediateIntermediate MRDMRD > 10> 10--44 and <
10and < 10--22
LLate monitoring =12 and = 24 mo : under study
FlowFlow cytometrycytometry (10(10-4))MolecularMolecular
biologybiology -- IgIg/TCR /TCR rearrear..
PCR 10PCR 10--22 –– 1010--55- Fusion transcritsFusion
transcrits
RTRT--PCR 10PCR 10--33 –– 1010--55
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GeneGene expression signatures expression signatures
predictivepredictive ofof responseresponseandand outcomeoutcome in
in highhigh--riskrisk childrenchildren
BhogvaniBhogvani D., JCO 2009D., JCO 2009
BoneBone--marrowmarrow content content d7 in d7 in highhigh
riskrisk patientspatients
ApoptosisApoptosis--facilitatedfacilitated genesgenes : :
upregulatedupregulated in in rapidrapid respondersresponders
Multiple Multiple genesgenes involvedinvolved in in cellcell
adhesionadhesion, , proliferationproliferation, ,
antiapoptosisantiapoptosis : : upregulatedupregulated in slow in
slow respondersresponders
AnalysisAnalysis ofof genegene expression profilesexpression
profilesrapidrapid approachapproach ofof biologicbiologic
understandingunderstanding ofof whywhy clinicalclinical
andand laboratorylaboratory variables are variables are
associatedassociated withwith outcomeoutcometo to improveimprove
treatmenttreatment
but but nono links links evokedevoked withwith causescauses
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ChildhoodChildhood AL : a multitude AL : a multitude ofof
diseasesdiseases
ProductProduct ofof alterationsalterations to to thethe
germlinegermline geneticgenetic andandepigeneticepigenetic code
code clonal clonal diseasedisease
•• MainlyMainly translocationstranslocations fusion
transcription fusion transcription factorsfactors or or
activatedactivated signalingsignaling kinaseskinases
•• AneuploAneuploïïdydy, , deletionsdeletions in in
cellcell--cyclecycle checkpointcheckpointgenesgenes andand
mutatedmutated genesgenes (FTL3, RAS, (FTL3, RAS,
otherothergrowthgrowth promotingpromoting pathwayspathways
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In In uteroutero originorigin ofof leukemiasleukemias
Short Short latencylatency ofof leukemiasleukemias
((infancyinfancy, , peakpeak age 2age 2--4 4 yrsyrs, ALL),
ALL)ExtremeExtreme developmentaldevelopmental andand cellular
cellular kinetickinetic stresstres ofof a fa fœœtustusConcordance
Concordance ofof leukemialeukemia in in twinstwinsArchivedArchived
newnew--bornborn bloodsbloods : : discoverydiscovery ofof
preleukemicpreleukemic clonesclones
Initiation : in utero Initiation : in utero exposureexposure to
to mutagenmutagen agents ?agents ?
••RearrangtsRearrangts ofof MLL MLL genegene atat 11q3 (+
chr.4,9,19) : 80 % 11q3 (+ chr.4,9,19) : 80 % ofof AML1 AML1
andand60 % 60 % ofof ALL (infants)ALL (infants)
••RearrangtsRearrangts ofof ETV6 ETV6 atat chrchr 12 + RUNX1 on
12 + RUNX1 on chrchr 21 (TEL21 (TEL--AML1)AML1)25 % ALL25 % ALL
••RearrangtsRearrangts ofof RUNX1/ETO RUNX1/ETO atat chrchr 8 in
15 % AML 8 in 15 % AML ••TrisomyTrisomy 21 : 1021 : 10--20 % AML 20
% AML andand ALLALL••NOTCH1 mutation in TALLNOTCH1 mutation in
TALL
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SecondarySecondary oncogeniconcogenic eventsevents
::obviouslyobviously neededneeded leukemiasleukemias
CordCord bloodblood screeningscreening ≤≤ 1 % positive for TEL1
% positive for TEL--AML, AML, onlyonly 1 % 1 % ofof themthem
leukemialeukemia
DownDown’’s syndromes syndrome•• 1st hit : 1st hit :
trisomytrisomy 2121•• AcquiredAcquired mutation mutation ofof
GATA1GATA1
TransientTransient leukemialeukemia atat birthbirth in 5in 5--10
% 10 % ofof childrenchildren•• FurtherFurther mutationsmutations M7
M7 leukemialeukemia
TELTEL--AML AML transloctransloc (t12 ; 21) + partial (t12 ; 21)
+ partial deldel (12p)(12p)
NOTCH1 mutation + SILNOTCH1 mutation + SIL--TAL fusionTAL
fusion
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RoleRole ofof firstfirst andand 22aryary
environmentalenvironmental±± genetic events?genetic events?
Most Most remainremain unknownunknown, , but new but new
technologictechnologicapproachesapproaches hypotheseshypotheses
concerningconcerning initiation initiation
andanddevelopmentdevelopment ofof BPCBPC--ALL (85 %) ALL (85 %)
andand TT--ALL :ALL :
•• TransfectionTransfection to animal to animal modelsmodels••
In In vitrovitro longlong--termterm cultures cultures ofof
leukemicleukemic cellscells•• Use Use ofof humanhuman
embryogenicembryogenic stemstem--cellscells•• SequencingSequencing
ofof humanhuman genomegenome, , analysisanalysis ofof
transcriptometranscriptome, comparative , comparative
genomicsgenomics, , genomegenomesequencingsequencing ofof tumoral
tumoral cellscells
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TELTEL--AML1 AML1 leukemialeukemia fusion fusion ETV6 ETV6 ––
RUNX1 t (12 ; 21) RUNX1 t (12 ; 21)
TheThe mostmost commoncommon chimericchimeric fusion fusion
genegene ofof BCPBCP--ALL ALL (1)(1)
A A preleukemicpreleukemic phenotypephenotype, ,
predominantlypredominantly in utero in utero (1 %) (1 %) ofof
newbornsnewborns))
A A keykey promotionalpromotional eventevent : an aberrant
immune : an aberrant immune responseresponse to to commoncommon
infections (infections (GreavesGreaves))
↓↓
Pre-B Cell ALL
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1919
TELTEL--AML1 AML1 leukemialeukemia fusionfusion (2)(2)
TELTEL--AML1 AML1 cancan a population a population ofof
selfself--renewingrenewinghumanhuman cordcord bloodblood cellscells
CD34CD34++CD38CD38--CD19CD19++,,veryvery earlyearly B B cellcell
stage (1stage (1stst hit)hit)to to sustainsustain a a persistent
persistent preleukemiapreleukemia statestate
InterferenceInterference withwith thethe TGFTGFββ pathwaypathway
((murinemurineand human model systems) and human model systems)
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2020
TELTEL--AML1 AML1 leukemialeukemia fusionfusion (3)(3)
TELTEL--AML1 expression AML1 expression inhibition inhibition
ofof responseresponse to TGFto TGFββTELTEL--AML1 AML1 cellscells
proliferateproliferate slowlyslowly, but , but
continuouslycontinuously, , untiluntil 22ndnd hit hit ALLALL
TGFTGFββ signalingsignaling contributescontributes to to
selfself--renewalrenewal andanddifferentiationdifferentiation + +
regulationregulation ofof immunologicimmunologic
andandinflammatoryinflammatory reactionsreactions
DysregulationDysregulation ofof TGFTGFββ signalingsignaling
((lossloss ofof sensitivitysensitivity) by ) by TELTEL--AML1 AML1
proteinprotein : blocks : blocks thethe abilityability ofof
TGFTGFββ to to contributecontribute to to cellcell
differenciationdifferenciation andand
suppresssuppressproliferationproliferation ofof cellscells..
== Argument in Argument in favorfavor ofof a a
dysregulateddysregulated immune immune responseresponse to to
infection, 2infection, 2ndnd hit : hit : malignantmalignant
evolutionevolution ofof thethe TELTEL--AML1, AML1,
preleukemicpreleukemic cloneclone
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PharmacogeneticsPharmacogenetics : influence : influence
ofofpolymorphismspolymorphisms ofof genesgenes involvedinvolved in
in severalseveral
metabolicmetabolic pathwayspathways
May May alteralter activityactivity ofof drugdrug
metabolizingmetabolizing enzymesenzymesefficacyefficacy andand
toxicitytoxicity ofof therapytherapy
May influence May influence thethe riskrisk for ALLfor
ALLGenesGenes involvedinvolved in in folatefolate
metabolismmetabolism pathwayspathways (DNA (DNA synthesissynthesis
andand repairrepair, , methylationmethylation
processus)processus)GenesGenes P450 P450 andand glutathion
glutathion SS--transferasetransferase
enzymesenzymesMultidrugMultidrug resistanceresistance genegene
(MDR1)(MDR1)NQO1 : NQO1 : protectsprotects againagain oxydative
stress oxydative stress andand toxictoxic
metabolitesmetabolites
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PresentPresent needsneedsBetterBetter evaluationevaluation
andand understandingunderstanding ofof thethe
heterogeneityheterogeneity andandcomplexitycomplexity ofof
leukemiasleukemias
•• New New molecularmolecular technicstechnics, animal , animal
modelsmodels, , humanhumanembryonicembryonic cellscells
•• RoleRole ofof leukemicleukemic stem stem cellscells andand
ofof stromastroma•• PharmacogeneticsPharmacogenetics (pt,
parents)(pt, parents)
New New epidemiologicalepidemiological
approachesapproachesTakingTaking intointo accountaccount thethe
multitude multitude ofof thesethese diseasesdiseases, ,
theirtheirmultimulti--stepstep developmentdevelopment
LargeLarge--scalescale studiesstudies includingincluding thethe
analysisanalysis ofof genogeno--environmentenvironment
interactions.interactions.
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ASN ASN WorkingWorking GroupGroup (1)(1)
BetweenBetween March March andand DecemberDecember 20082008
Objectives :Objectives :
•• To To evaluateevaluate, if possible, , if possible, thethe
realreal riskrisk ofof childhoodchildhoodleukemiasleukemias in in
thethe vicinityvicinity ofof nuclearnuclear sitessites
•• To To betterbetter approachapproach thethe knowledgeknowledge
ofof causal causal geneticgeneticandand environmentalenvironmental
factorsfactors ofof childhoodchildhood leukemiasleukemias
•• To To clarifyclarify thethe content content ofof
communicationcommunication givengiven to to thethepopulation,
population, whichwhich needsneeds to to receivereceive
neutralneutral, transparent , transparent andandupdatedupdated
informationinformation
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ASN ASN WorkingWorking GroupGroup (2)(2)
ItIt has been has been decideddecided to propose to propose
underunder thethe auspices auspices ofof ASN :ASN :
•• A A pluralistpluralist andand
pluridisciplinarypluridisciplinary workingworking group group
ofofexpertsexperts ((institutionalinstitutional andand
independentindependent) in : ) in : hematologyhematology, ,
epidemiologyepidemiology, , nuclearnuclear industryindustry, ,
chemistrychemistry, , infectiologyinfectiology, ,
immunologyimmunology……
•• A national A national committeecommittee in charge in charge
ofof followfollow--upup ofof thetheworkingworking groupgroup andand
particularlyparticularly itsits proposalsproposals withwith thethe
aimaim to to promotepromote thethe mostmost appropriateappropriate
epidemiologicalepidemiological future future studiesstudies
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ASN ASN WorkingWorking GroupGroup (3)(3)
FiveFive meetings meetings ofof thethe workingworking group
group betweenbetween DecemberDecember2008 2008 andand
SeptemberSeptember 2009, 2009, usuallyusually in in thethe
presencepresence ofofB. GROSCHEB. GROSCHE
•• Descriptive Descriptive andand analyticanalytic
epidemiologicalepidemiological FrenchFrenchstudiesstudies
((geneticgenetic andand environmentalenvironmental
factorsfactors))
•• NuclearNuclear sitessites, , andand activation activation
ofof a a specificspecific subsub--group group listing listing ofof
sites, types, classification, sites, types, classification,
surroundingsurroundingpopulation, types population, types andand
measuresmeasures ofof rejet rejet
•• LeukemicLeukemic stem stem cellscells•• GermanGerman pastpast
andand presentpresent studiesstudies
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ChildhoodChildhood AL : a multitude AL : a multitude ofof
diseasesdiseases
A lot A lot ofof potentialpotential causes causes severalseveral
hypotheseshypotheses•• a lot a lot ofof casecase--controlcontrol
studiesstudies•• a lot a lot ofof controversialcontroversial
datadata
Future Future epidemiologicepidemiologic studiesstudies have to
have to bebe designeddesigned aroundaround
thethecharacterizationcharacterization ofof thethe
childhoodchildhood acute acute leukemiasleukemias, , withwith
thetheaimaim to to betterbetter approachapproach thethe
relationshipsrelationships betweenbetween thethe causes causes
andand thethe consequencesconsequences ofof thethe
developmentdevelopment ofof thethe ((prepre))--leukemicleukemic
cellcell andand notablynotably thethe rolerole ofof postpost--natal
natal factorsfactors
A multitude A multitude ofof epidemiologicalepidemiological
studiesstudies
ADVANCES IN CHILDHOOD ACUTE LEUKEMIAS : GENERAL
OVERVIEWDefinition of acute leukemiasInteractions between the
patient and his disease (1)Interactions between the patient and his
disease (2)Advances (1)Advances (2)Current risk stratification in
ALBPC-ALL prognostic factors at diagnosis risk groups (1)BPC-ALL
prognostic factors at diagnosis risk groups (2)BPC-ALL prognostic
factors at diagnosis risk groups (3)Prognostic factors
in-ALLMinimal residual disease : a major criteria of therapeutic
decisional value (ALL)Gene expression signatures predictive of
response and outcome in high-risk children Bhogvani D., JCO
2009Childhood AL : a multitude of diseasesIn utero origin of
leukemiasSecondary oncogenic events : obviously needed
leukemiasRole of first and 2ary environmental ± genetic
events?TEL-AML1 leukemia fusion ETV6 – RUNX1 t (12 ; 21) The most
common chimeric fusion gene of BCP-ALL (1)TEL-AML1 leukemia fusion
(2)TEL-AML1 leukemia fusion (3)Pharmacogenetics : influence of
polymorphisms of genes involved in several metabolic
pathwaysPresent needsASN Working Group (1)ASN Working Group (2)ASN
Working Group (3)Childhood AL : a multitude of diseases